The Theoretical Integrative Review—A Researcher’s Guide

The first step in a TIR is to identify and define the context—the phenomenon of interest—that will be the focus of the review. This could be an area relevant to specific HPE work and responsibilities with which the reviewer already has some practical knowledge (eg, empathy, well-being, medical error), or it could be a phenomenon that has yet to be deeply explored in HPE (eg, experiences of shame in graduate medical education).

Once the phenomenon has been identified, it must be clearly defined for the purposes of the review—what it is and what it is not. For example, in the context of graduate medical education, professional identity formation could be considered across a range of orientations, including those that are individual-focused (eg, identity status theories and narrative approaches) and those that are social-focused (eg, social identity theory and self-categorization theory).¹  Alternatively, the reviewer could narrow the scope of the TIR to one of these foci, or restrict it even more to study particular subgroups of theories within larger divisions. By defining the phenomenon and the scope of inclusion that will shape the TIR, the author is already beginning the process of the review itself, because framing structures must be informed by a nuanced understanding of the theories available in the literature.

Once the phenomenon of interest for the TIR has been defined, a team should be assembled to support the review work. As with other types of reviews, a research librarian or information specialist can be very helpful in planning, conducting, and describing literature searches. Other collaborators should include scientists or scholars who have knowledge of the phenomenon of interest and/or expertise in analyzing theory. These colleagues may come from health care professions, but they are also likely to be found in other disciplines, such as sociology, educational psychology, or philosophy. Because the work of studying theory is a highly conceptual endeavor, enlisting the support of scholars who are comfortable wrestling with abstract notions is strongly recommended. Early in the process these colleagues can shed light on specific theories from their disciplines, which can help inform understanding of the phenomenon, the premises central to the theories’ explanatory power, and current debates contesting conceptualizations of the phenomenon.

Once in place, the TIR team’s first task is to begin exploring the literature, an endeavor ideally guided by a research librarian. While this search need not be all-inclusive (ie, not every theory to ever address the phenomenon of interest must be incorporated into the review), a convincing rationale for the TIR’s scope of inclusion must be communicated. This justification is an important component of the TIR’s rigor, since it defines the parameters for the search. In other words, the framing offered by this rationale sets readers’ expectations for the selection of the theories that are part of the review. If the TIR fails to include a theory that sits within the defined scope of inclusion, the review stands to be critiqued for weak search efforts.

The databases and search terms, as well as secondary search strategies—to include books and other publications not in peer-reviewed journals—must be presented as part of the TIR’s methods. Given that theory is not always presented in peer-reviewed journals, the expertise of the research librarian will likely be needed to find relevant publications. This is particularly important when working with undertheorized phenomena (ie, topics that are addressed by few theories), because the TIR review team will need to demonstrate that the theory has not been robustly developed in relation to the phenomenon, rather than simply having been undetected in the search.

Although the methods of searching the literature are a critical element across different types of reviews, much of the effort in this step involves exploring the literature through recursive deep readings. In this work, the TIR authors strive to become familiar with the abstract conceptions characteristic of the theory, explicitly identify the premises of the theory, and explore the logical connections between these premises. In addition to reading, conversations among the TIR’s cross-disciplinary collaborators will help develop and vet the team’s understanding of the theories being examined.

After initial exploratory readings and discussions, the TIR team moves to critically examine all the theories that form the TIR corpus. Parse identifies 2 different categories of criteria for studying theory: structure and process.²  For structure, Parse recommends evaluating each theory in terms of its historical origins and evolution; its foundational elements, including the embodied philosophical assumptions and conceptualizations; and relational statements of how these assumptions and conceptualizations weave together in the theory. Regarding process, Parse advises studying each theory in terms of its correspondence (ie, the simplicity and clarity of the theory’s description and the semantic integrity of the ways in which assumptions, conceptualization, interrelations, and meanings are integrated); its coherence (ie, the syntax or logical flow of the elements of the theory and the aesthetics of the theory); and its pragmatics (ie, the effectiveness of the theory for guiding research and practice and heuristic potential to support further research using the theory).³ 

There are no specific, predefined process steps offered in support of TIRs. This is partly because the precise nature of the end product of the review team’s work is not known. If many relevant theories are identified, the product may be a revision to a particular theory or an amalgamation of several premises from different theories. It may be the development of a new theory if a gap is identified in the body of existing theories or if few relevant theories are found in the search. In this latter case, the TIR shifts to synthesizing a theoretical structure de novo, through integrating aspects of relevant theory from other disciplines. The prescription of more detailed process steps is also hampered by the fact that TIR authors are unable to predict what will be found within each theory. Unlike systematic reviews, where manuscripts are included only if specific kinds of data are presented, the TIR can include manuscripts describing theories with a variety of different purposes (eg, descriptive, explanatory, predictive) and a range of different levels (eg, macro, middle-range, micro). Given such diversity, more specific methods are not available; instead, TIR research teams will address Parse’s criteria in unique ways. Therefore, in the TIR’s description of methods, the ways in which these criteria were met must be clearly described so that readers can understand the study’s analytic progression.

Simply put, theoretical integration is the communication of the knowledge developed via the TIR’s critical investigation of the included theories. In addition to clear writing, graphic representations of new ideas—or clarifications of existing ones as they relate to specific phenomena—can help convey these ideas effectively. In addition, the TIR should be directive, by pointing out what work is still needed and identifying specific next steps for researchers who would like to contribute to future efforts in the area.

This work was supported in part by the Department of Veterans Affairs Office of Academic Affiliation Advanced Fellowship in Health Professions Education, Evaluation, and Research, and by the George E. Wahlen Veterans Affairs Medical Center of Excellence in Musculoskeletal Care and Education.